Extramammary Paget's disease: a novel approach to treatment using a modification of peripheral Mohs micrographic surgery.

Extramammary Paget's disease is a rare intraepithelial adenocarcinoma typified histologically by the presence of Paget cells. Treatment has historically been surgical, with wide excision being the standard of care. However, due to clinically indeterminate margins and diffuse spread, local recurrence rates remain high. Mohs micrographic surgery has been proposed to improve the rate of local recurrence. Application of Mohs technique to treat extramammary Paget's disease can be difficult because of the large size of these lesions. Reported excisions either involved lengthy procedures or peripheral Mohs modification. The peripheral technique does not evaluate the depth of the central lesion, yet prognosis and lymph node involvement are directly related to the degree of vertical invasion. In this study, we discuss our experience with extramammary Paget's disease, along with a novel approach to treatment by using a modification of peripheral Mohs micrographic surgery that incorporates histologic analysis of the central specimen's depth.

Lentigo maligna: diagnosis and treatment.

Lentigo maligna is an overgrowth of atypical melanocytes at the dermal-epidermal junction also known as melanoma in situ. Left untreated, these lesions can continue to grow, resulting in dermal invasion and progression to lentigo maligna melanoma. Many operative and nonoperative treatments have been developed with the goals of preserving function and cosmesis while at the same time addressing the diffuse nature of these lesions. Previous recommendations have led plastic surgeons to commonly perform wide local excision with 5 mm margins. More recent literature has suggested that in many cases this treatment can result in high recurrence rates. This has led to margin control procedures becoming the treatment of choice for these lesions.

Staged excision of lentigo maligna and lentigo maligna melanoma: a 10-year experience.

BACKGROUND: The treatment of lentigo maligna and lentigo maligna melanoma presents a difficult problem for clinicians. Published guidelines recommend a 5-mm excision margin for lentigo maligna and a 1-cm margin for lentigo maligna melanoma, yet these are often inadequate. The authors' purpose is to report their 10-year experience using staged excision for the treatment of lentigo maligna and lentigo maligna melanoma of the head and neck. METHODS: Staged excision was performed on 59 patients over a 10-year period. Data on patient demographics, lesion characteristics, and treatment were collected through an institutional review board-approved chart review. RESULTS: Using staged excision, 62.7 percent of patients required a 10-mm or greater margin to achieve clearance of tumor. Two or more stages of excision were required in 50.9 percent of patients. Invasive melanoma (lentigo maligna melanoma) was identified in 10.2 percent of patients initially diagnosed with lentigo maligna. There was one (1.7 percent) documented recurrence during a median 2.25-year follow-up period (range, 0 to 10.17 years). CONCLUSIONS: Staged excision is an effective treatment for lentigo maligna and lentigo maligna melanoma. Previously published recommendations of 5-mm margins for wide local excision are inadequate for tumors located on the head and neck.